Primecuts – This Week In The Journals

By Meng Chen, MD

Peer Reviewed

Last Friday, in an announcement of hope and optimism, Reuters quoted a senior health official from Liberia as reporting only five remaining confirmed cases of Ebola in Liberia, which was once an epicenter of the deadly disease outbreak that has killed more than 8,600 people in western Africa. [1] Deputy Health Minister Tolbert Nyenswah, who leads Liberia’s Ebola task force, believes that Liberia could be Ebola-free by the end of February, saying “It means that we are going down to zero, if everything goes well, if other people don’t get sick in other places.” [1] This is in stark contrast to the worst of the epidemic several months ago, when Liberia was reporting 500 new infections per week. [2] Guinea and Sierra Leone are also seeing falling infection rates. [2] Through a tremendous international response and tenacious local dedication, this marks a clear turning point in the ongoing fight against the worst Ebola outbreak in history and is an attestation to human potential in overcoming daunting public health challenges through collaboration and dedication.

Overshadowing rare instances of fear-mongering and ignorance by a few public figures, the US made significant contributions in the international campaign against Ebola, including numerous courageous volunteer healthcare workers and “hundreds of US troops deployed to build treatment centers.” [1] However, any healthcare workers returning home this week may be met with an icy, windy welcome. Beginning Monday evening, weather experts are anticipating a “monster snowstorm” stretching throughout the Northeast, including possible coastal flooding, freezing rain, hurricane-level wind gusts, and up to 3 feet of snow in New York and Boston. [3] It is expected to be “one of the largest snowstorms in the history of this city”, said New York City Mayor Bill de Blasio. [3] In these situations, it is important to be cognizant of hypothermia signs, which include significant shivering, mental confusion, new amnesia, difficulty speaking, muscle incoordination, paleness, and cyanosis of lips, ears, fingers, or toes. Staying indoors as much as possible sounds like the best bet during these next few days. However, as our next article emphasizes, being too inactive can lead to worse health outcomes.

Sedentary Time and Its Association With Risk for Disease Incidence, Mortality, and Hospitalization in Adults: A Systematic Review and Meta-analysis. [5]

In yet another indictment of today’s car-driving, desk-centered culture, CNN highlighted a new report last week asserting that prolonged sedentary behavior is associated with increased risk of death, independent of exercise. [4] The authors of the article, published in last week’s edition of Annals of Internal Medicine, concluded this after performing a meta-analysis of 47 primary studies from the literature that examined the relationship between sedentary behavior independent of physical activity and health outcomes. [5] Sedentary behavior was defined as waking activities requiring little physical movement and low-energy (?1.5 metabolic equivalents), such as sitting, watching TV, and reclined posture. After analyzing the data and performing statistical adjustment for physical activity, they found significant hazard ratios for sedentary time and increasing risk for “all-cause mortality, cardiovascular disease incidence or mortality, cancer incidence or mortality (breast, colon, colorectal, endometrial, and epithelial ovarian), and type 2 diabetes in adults.” In fact, prolonged sitting for 8 or more hours a day—the typical American work-day—resulted in a 90% increased risk of developing type 2 diabetes. CNN concluded “sitting will kill you, even if you exercise”, [4] which is quite unsettling since sitting is still one of life’s simple pleasures. Nonetheless, the next time a commercial break comes on, just take a 60-second stroll!

The Implications of Marijuana Legalization in Colorado [6]

In addressing a different type vices enjoyed by some people, an article in JAMA last week evaluated the consequences of Colorado’s legalization of marijuana back in November 2012. [6] Marijuana and its tetrahydrocannabinol (THC) content has been speculated to have anti-inflammatory effects, along with known analgesic and appetite-simulating properties that may make it useful, for example, in patients with cancer. However, not surprisingly, the authors reported an associated increase in emergency department (ED) visits for marijuana intoxication since legalization, including symptoms of “anxiety, panic attacks, public intoxication, vomiting, or other nonspecific symptoms precipitated by marijuana use.” Additionally, frequent exposure to high levels of THC can lead to cyclic vomiting, and two Denver EDs were found to have an increase in cyclic vomiting cases from 41 per 113,262 ED visits to 87 per 125,095 ED visits (prevalence ratio 1.92). There has also been a significant increase in marijuana-related burn cases seen at the UC burn center. Perhaps more worrisome is a notable increase in pediatric cases of marijuana ingestion in EDs throughout the state. The study called for more standardized THC concentrations and better childproof packaging of edible marijuana products. In examining these recent outcomes, the authors aimed to refine the regulatory process in marijuana legalization in Colorado and other states that may legalize it in the future.

D-Dimer Testing to Select Patients With a First Unprovoked Venous Thromboembolism Who Can Stop Anticoagulant Therapy: A Cohort Study. [7]

Another recent issue of Annals of Internal Medicine published an article suggesting an additional use for the often-misused d-dimer test, which currently is only recommended for ruling out venous thromboembolism (VTE) if the test returns negative in the setting of low pre-test suspicion. [7] In this multicenter, prospective cohort study of 410 patients, the authors focused specifically on the utility of the d-dimer to predict the recurrence of unprovoked VTEs after treatment cessation. While provoked VTEs with a reversible risk factor have low recurrence risk after anticoagulant treatment cessation, unprovoked VTEs are often treated indefinitely. In the study, patients with unprovoked VTEs who completed 3-7 months of anticoagulant treatment underwent two d-dimer tests 1 month apart; of 419 initial patients, 319 patients were discontinued off of anticoagulant therapy after negative d-dimers. The authors found that while the risk of recurrence was not low enough among men who discontinued anticoagulation (9.7% per patient-year, CI 6.7% to 13.7%), it may be low enough among women to justify stopping anticoagulant therapy after 2 negative d-dimers. The risk of recurrence was 5.4% (CI 2.5% to 10.2%) per patient-year in women who had VTEs not associated with estrogen therapy (9 of 81) and was 0.0% (CI 0.0% to 3.0%) per patient-year in women with VTE associated with estrogen therapy (0 of 58).

Institute of Medicine report on GME–a call for reform. [8]

Shifting to a broader perspective, the most recent health policy report in the NEJM from last week addressed current trends in graduate medical education (GME) funding. [8] Specifically, it described the key areas and controversies surrounding the most recent GME report in July 2014 by the Institute of Medicine (IOM) [9], which is a non-governmental organization aimed at advising the nation on issues of medicine and health. GME in America is supported mostly by Medicare, with an annual GME payout of $9.7 billion in 2012. While the IOM panel maintained that GME training in America is a model system followed by many countries, they also emphasized that GME programs supported by Medicare are not training enough physicians to work in needed specialties or underserved areas. Additionally, the panel sought to address an overarching question: “To what extent is the current GME system producing an appropriately balanced physician workforce ready to provide high-quality, patient-centered, and affordable health care?”

These issues became especially pertinent in the wake of the recent November 2014 elections, in which “Republicans secured strong majorities” in a new Congress seeking to cut government costs, which may include GME funding. [8] In this context, the IOM panel recommended a gradual replacement of current Medicare GME payment formulas with a more transparent, performance-based system. Specifically, it outlined the potential creation of two new Medicare funding sources. An “operational fund” would continue to provide a “single payment” to accredited GME programs, adjusted geographically and per program. A second “transformational fund” would provide additional funding based on performance measures, innovative projects, specialties-in-need, and geographic areas. Strong and immediate backlash came from the AHA, AMA, and AAMC. Many asserted that these changes would lead to significant overall reductions in Medicare GME funding for teaching hospitals, which would further worsen physician shortages across all specialties.

Various interests of subgroups and different geographic areas are also mixed into the controversy. As the battles between different interest groups on Capitol Hill wages on, all entities seem to agree that a critical juncture in healthcare policy and GME policy in particular is near. A recent report in the AAMC stated it thus: “Every aspect of academic medical centers will undergo transformation in the decades ahead…” [8]

Other new developments…

A sense of immunity: Scientists are detailing the immune system as never before. [10]

Immune pathways underlie almost every disease process seen across the various medical and surgical specialties. With B and T cells making immune receptors that can have up to 10 trillion sequence variations from recombination and mutation mechanisms, it is not surprising that something can go wrong along the way. This recent article in Nature Medicine highlights current efforts by immunologists at the Human Immunology Project Consortium and various other institutions to utilize new technologies that can read millions of genetic sequences at one time, thus allowing more detailed exploration into how immune receptor sequence variations can affect mechanisms in response to infections, cancer, and immunization.

Bridging the Hospitalist–Primary Care Divide through Collaborative Care [11]

Over the past quarter-century, there has been a fast-growing and increasingly visible trend of hospitalists providing general medicine inpatient care, coinciding with the near disappearance of primary care physicians (PCPs) from the inpatient setting. With numerous forces driving this movement, hospitalist care has been found to have numerous benefits, with increased efficiency and similar quality. However, this dichotomy of patient care between the hospitalist and the PCP has lead to new challenges in provider communications, role definitions, and payment reforms that this article in NEJM seeks to address.

A rationally designed monomeric peptide triagonist corrects obesity and diabetes in rodents. [12]

With the ever-looming epidemics of obesity and diabetes growing both here and around the world, much research has focused on finding new agents to assist with managing weight loss and diabetes. This new study published in Nature Medicine in December 2014 reports the discovery of a novel monomeric peptide that acts as an agonist on three key hormone receptors, including GLP-1, GIP, and glucagon. With the potential to become a highly effective therapy for obesity and the metabolic syndrome, this agent was superior to any other current receptor agonist in promoting weight loss, enhanced glycemic control, and hepatic steatosis reversal in rodent models.

Dr. Meng Chen is a 1st year resident, Medicine, NYU Langone Medical Center

Peer reviewed by Anish B. Parikh, MD, 3rd year resident, Medicine, NYU Langone Medical Center

Image courtesy of Wikimedia Commons

References:

[1] http://www.reuters.com/article/2015/01/23/us-health-ebola-liberia-idUSKBN0KW27T20150123

[2] http://www.ibtimes.com/ebola-outbreak-update-only-five-cases-left-liberia-report-says-1793784

[3] http://www.cnn.com/2015/01/07/weather/cold-weather-hypothermia/index.html

[4] http://www.cnn.com/2015/01/21/health/sitting-will-kill-you/index.html

[5] http://annals.org/article.aspx?articleid=2091327

[6] http://jama.jamanetwork.com/article.aspx?articleid=2022370

[7] http://annals.org/article.aspx?articleid=2088546

[8] http://www.nejm.org/doi/full/10.1056/NEJMhpr1413236